Monday, November 17, 2008

JindalCare is JEB!Care

BATON ROUGE — Arguing that “doing nothing is not an option,” Gov. Bobby Jindal on Friday proposed restructuring Louisiana’s health-care program for the poor into a private insurance model that relies on managed-care principles to control costs and improve health outcomes.

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Jindal’s plan calls for pilot programs in four regions — New Orleans, Baton Rouge, Shreveport and Lake Charles — where most Medicaid recipients would be required to choose between competing managed-care networks. The state would provide “choice counselors” to help people pick between the plans, and people who don’t choose would be automatically enrolled in a plan.

Pilot regions, Medicaid recipients have to choose between competing managed-care networks, choice counselors, and automatic enrollment if you don’t/can’t decide among the competing plans — all are straight out of the Florida “Medicaid Reform” playbook.

That couldn’t possibly have anything to do with the fact that Alan Levine, formerly the director of Florida’s Agency for Health Care Administration [which oversees Medicaid in FL] and implementer of a “medicaid reform” pilot project here [back when JEB!, brother of Dubya, was governor] is now head of Louisiana’s DHH [which oversees Medicaid in LA], could it? Ha!

So, just how is that Florida Medicaid Reform pilot project working out anyway?

You can read the final report for year 2 if you like [big PDF], but the question I most want answered is — according to the report, 287,015 people enrolled in the program, but 111,603 disenrolled — why?

Anyways, on first reading [and second, and third, if you want to know] I didn’t find much in that report that report that could be termed actual data, though there are lots of numbers and tables scattered throughout, and none of those numbers and tables addresses actual health outcomes. It’s all stuff about utilization of call centers, and grievances, and coupons for baby diapers and children’s Tylenol given out as rewards for “making healthy lifestyle choices.”

The Baton Rouge [LA] Business Report has the best wrap-up I’ve found so far. Some excerpts from an article, Market Forces —

Gov. Bobby Jindal’s administration wants to move fast to secure a federal waiver to implement Medicaid reform in Louisiana, the idea being to improve the delivery of health services to low-income families and the disabled, resulting in a healthier population, more accountability and significant savings.

Guiding the effort is Alan Levine, Jindal’s secretary of Health and Hospitals, who oversaw a similar experiment in Florida as Medicaid adviser to former Gov. Jeb Bush. Levine says the Florida pilot projects have been mostly successful. Several critics have come to the opposite conclusion, although Levine says such criticisms have not been based on reliable data.

And though the details aren’t even close to being worked out, Levine is convinced Louisiana’s reform effort will succeed in part because of how it will differ from Florida’s.

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Florida Medicaid reform is performing admirably or not, depending on whose study you believe. A July report from the Community Health Action Information Network, a patient advocacy group, says the Florida Agency for Health Care Administration vastly inflated the savings created by reform. A survey of doctors by the Health Policy Institute at Georgetown University seems to point to a decline in physician participation since reform.

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Florida’s Medicaid reform pilots started in 2006 in Broward and Duval counties, and in 2007 was expanded to three more counties. A report by former AHCA Inspector General Linda Keen found problems with the pilots, however, and Medicaid reform was not expanded to other counties. Keen has since stepped down, and AHCA has a new secretary, Holly Benson, who is expected to push ahead with expanding reform.

In response to criticism, Levine cites a report by the James Madison Institute, a free-market think tank, that argues previous studies on reform are flawed and that competition in the pilot counties has been spurred and significant cost savings realized.

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Levine says Louisiana’s transformation of Medicaid will look like Florida in the general sense of bringing the marketplace to bear in solving problems. In the pilot programs, residents eligible for Medicaid could choose among HMOs or other health networks called Provider Service Networks.

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In Florida, the PSNs and HMOs compete against each other, with the marketing advantage going perhaps to the HMOs, which have been ensconced in the Florida Medicaid market for years. In Louisiana, individual PSNs will be managed by HMOs and compete against other PSN/HMO teams.

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Levine’s agency will require HMOs to partner with a provider, which he says creates a “natural, market-based filter.” DHH will do an actuarial analysis to decide how many HMO/PSNs a given market requires. DHH will decide which HMOs get in based on metrics such as history of patient satisfaction, promptness of payment, etc. The HMOs that make the cut will compete against each other in that market. That way, the state is out of the business of setting Medicaid rates. The HMOs do it instead—which is probably not going to be music to most doctors’ ears.

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If reform through managed care is not more economical than old fashioned fee-for-service, it’ll be a hard sell taking the concept statewide. Studies are under way that everyone hopes will answer that question. Doctors in the pilot counties, meanwhile, are divided on reform depending on how much bargaining power they have with HMOs or PSNs to get higher rates of reimbursement from Medicaid. Scarce specialists are likely to have more bargaining power. Primary care doctors, who aren’t as scarce, are likely to have less.

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Dr. Steven Spedale is a Baton Rouge pediatrician and member of Levine’s advisory committee, representing the Louisiana chapter of the American Academy of Pediatrics. Spedale says it’s too early to know how well Florida’s Medicaid reform will work, since only three years have passed in what was designed as a five-year demonstration project.

“It’s hard to hold it out as the model to use because no one has the final numbers,” he says.

So, in Florida, a patient advocacy group says the reported savings were inflated, the Inspector General found problems with the program, but a free-market think tank says that: previous studies on reform are flawed and that competition in the pilot counties has been spurred and significant cost savings realized. Who ya gonna believe?

So it is fair to conclude that the state (again with a federal funding match available) has cut its commitment to insuring children from poor families to about two-thirds of what it was a few years ago. The problem is made worse by the unwillingness of private health insurance to cover children. Florida is tied for second-worst in the country in the percentage of uninsured children aged 0-18.